Conflict Prevention through Public Health Intervention

Guest,  Kaveh Khoshnood, PhD, Yale School of Public Health

22 March 2016

Frank Boudon: I’m Frank Boudon, Yale undergraduate and interviewer for the Early Childhood Peacebuilding Consortium Online Platform. Today we’ll be speaking with Dr. Kaveh Khoshnood, an esteemed Yale professor who is the director of undergraduate studies at the School of Public Health. He is also an epidemiologist with decades of experience dealing in particular with HIV prevention research. He is currently working on a parenting intervention with Palestinian refugees that is of particular interest to us.

So, Kaveh, why do you have an interest in the topic of violent conflict and early childhood health and development?

Kaveh Khoshnood: Hi Frank. My interest in the topic really comes out of my own sort of personal background. I was born in Iran and when I was a teenager there was a revolution against the Shah, and he was toppled and the Islamic Republic came to power. Shortly after that, the war between Iran and Iraq began – the bloody, eight-year war from 1980 to 1988. Although I was too young to be sort of involved in the war, I saw the devastation that the war causes. I lost cousins, I saw the damage to infrastructure, I saw people fleeing, and that impacted me as a teenager. So I left Iran, and I was fortunate to be able to come to the United States and stay with my uncle in Florida and continue my education here. So that early experience stayed with me, and when I, you know, became a professor at the School of Public Health, I began thinking about what is our role in prevention of conflict, right? Conflict around the world. It was sort of an attempt to answer that question that got me involved in some of the teaching and some research that I’m doing now.

Boudon: So, what exactly do you think is the role of public health professionals in the prevention of conflict, with particular emphasis on children and families?

Khoshnood: I mean if you think about it, public health, the goal of public health is prevention. The entire profession is summarized in prevention. That is what we try to do, whether it is drug addiction, HIV/AIDS, asthma, or, in this case, violence. So there ought to be a role for us. When it comes to violence, the World Health Organization divides violence into three categories: self-directed, so we can think of suicide as an extreme form of that; interpersonal violence like family violence, domestic violence, those kind of issues. Then this third category is called collective violence, which is basically where groups of individuals in an organized fashion commit acts of violence against other groups. But they’ re doing it not randomly – they’re doing it with very specific political, economic, social objectives. In this large category of selective violence, war resides and civil conflict resides. 

I was asking myself what is it that we can do when it comes to collective violence. Because, in terms of the first two categories, self-directed and interpersonal violence, I feel like there is some of that, there is some research. There are interventions that have been attempted and evaluated. But when it comes to collective violence, I see almost a silence around it. When I looked around at the School of Public Health, there wasn’t a single course that dealt with his topic. I actually started looking around at other schools of public health and, with a few exceptions, there really wasn’t a focus on the prevention of violent conflict.

So in 2013 I had the opportunity to take a sabbatical and go on leave from my regular teaching and administrative duties, and I decided to return to the Middle East. I had some connections with the American University in Beirut, Lebanon. I knew that given their location, they are surrounded by refugees. You may know that one out of every four persons in Lebanon is actually a refugee from Syria, which is astonishing. It would be something like the equivalent of 70 to 80 million refugees coming to the U.S. in the course of a couple years. So I went there to see what the public health community and what the public health academics at the American University of Beirut were doing in terms of teaching, in terms of research, in terms of involvement in the field, and I learned a great deal. I met some fantastic colleagues who I’m still in touch with over the last couple years.

I began to take some action.  So the first thing I did during that sabbatical year was I developed a course. That’s the course that I’m teaching now on conflict and health, and tried to really articulate the role of epidemiology and public health professionals. That course, which there is some involvement from colleagues at the American University in Beirut as they participate in the course through video conferencing, that’s been going on. I taught it last year and I’m teaching it again now.

I’ve started getting involved in collaborative research projects, again with colleagues in Lebanon and other places. So, when we think about prevention in public health we often categorize it as primary, secondary, and tertiary prevention. Primary prevention would be efforts that are intended to prevent something bad from happening in the first place. So if we can immunize children against polio so they don’t get polio at all, obviously that’s the best thing to do. So with infectious disease, we have some tools, vaccines in particular.

When it comes to more of a socially constructed problem such as conflict, where it has social, political, economic—and environmental sometimes— determinants, primary prevention is much more challenging, complicated, messy. You have to think about all the root causes of conflict and think about how you can address them. Those are the kinds of efforts I feel our political science colleagues are much more skilled at addressing. When it comes to secondary prevention, which is basically the space where bad things have already started—using the infectious disease model you have some cases of, lets say Ebola or Zika virus these days, and you try to contain it. So that would be secondary prevention, where you try to prevent further spread.

When it comes to violence, we could look at the same way. We could basically ask, “once conflict erupts, how can we contain it? Are there strategies that can be utilized to reduce its negative impact?” And there are things that we can do. Tertiary prevention is more about rehabilitation, reintegration, rebuilding. So think about child soldiers: once the hostility ends, these child soldiers need a long process of rehabilitation so they do not go back into committing acts of violence. That would be a tertiary prevention. So those are the three large categories of prevention. As I mentioned before, I feel secondary prevention is where a lot of the public health community has been focused. I would like us to move more towards primary prevention. But in doing so we need support from other colleagues in political science, law, history, and others who can help us understand its root causes.

Boudon: So in order to address the sorts of issues that you saw in Lebanon, could you describe the parenting intervention that your research group is working on? What are some of the main challenges in evaluating programs that involve young children in refugee centers?

Khoshnood: So I had the opportunity to get involved in a project that is led by my good friend and colleague, Jim Leckman, at the Yale Child Study Center. And that project is a parenting intervention. It’s for mothers and young children of preschool age who don’t have access to regular preschool education or training, which we know benefits mothers and children for decades to come. So there has been good, solid evidence showing these parenting interventions work well.

However, these interventions have never been implemented and rigorously evaluated in a fragile setting such as a refugee camp. So we were able to partner with colleagues in Lebanon—in particular Arab Resource Collective, which is an NGO that has a long-standing presence in Lebanon working both with the Lebanese population and refugees. They’ve been working with the Palestinian refugees that have been in Lebanon for decades, and they are now also working with the more recent arrivals of Syrians. Some are also Palestinian origin and some are Syrian nationals. So this particular intervention that we are in the midst of is a 25 week long intervention focusing in on mothers and their young children. We are implementing and evaluating this in two Palestinian refugee camps and one sort of community center for the low-income Lebanese population.

The idea is to implement it in a randomized fashion, which is very challenging, and due to ethical considerations we are not doing a placebo-controlled study. The way we structured and organized it is what we call a wait-list control: one group of mothers and their children will get the intervention, and then 25 weeks later we move on and offer the same intervention to the wait-list control. We do a baseline and end-line evaluation to see if there are changes in some outcomes, both mothers’ outcomes but also children’s outcomes in terms of readiness for school and all sorts of cognitive functions. But also we are looking at things like how parents discipline their children, the extent to which violence is used or physical force is used. So it’s a very quantitative study.

We decided early on that given the complicated context of the refugee camp—there is so much going on—it would be a missed opportunity if we did not also collect some qualitative data, which helps us understand the environment within which this particular intervention is being implemented. So we have a modest qualitative data collection component—which includes interviewing the directors of these camps and the centers that are operating in these camps, doing focus group interviews with the mothers when they start the program and when they complete it—just to try to get a sense of some of the environmental factors. And, perhaps not surprising is that we are learning a lot of really interesting information that I think we would’ve missed if we didn’t do that kind of qualitative interviews. So I’m happy to talk about some of those.

Boudon: Sure, so do you want to describe one of those qualitative interventions?

Khoshnood: So one of the things that we learned early on is that, although this program was intended for Palestinian refugees who have been there for a long time and multiple generations, there are a lot of new arrivals from Syria of Palestinian origin. So these are basically Palestinians who got uprooted from their homes, moved to Syria, established homes there, and because of the civil conflict in Syria had to move once again, this time coming to Lebanon. They went to the very same refugee camps that are already overcrowded with refugees who have been there 1948. So it’s created a lot of tensions. You have extreme overcrowding. I have walked through some of these camps and you could have one or two bedroom house that already has let’s say seven or eight people in it, and now you have another family come from Syria. It complicates things.

There is a very real constrain on resources, the basic necessities of life. So it’s created a lot of tension. Although the Palestinians who have been living in Lebanon would like to be welcoming, however they have very very very limited resources themselves. As a result we decided we couldn’t only offer the intervention to Palestinian mothers from Lebanon, we had to also offer it to some of the new arrivals from Syria. Also there’s been, in several very unfortunate incidents, there has been a couple of bombings. As a matter of fact right before the Paris bombing there was a pair of suicide bombings right at the entrance of one of these camps that we work in.  We’re extremely concerned about the safety of the residents of the camp and also the staff that we work with.  In fact the work had to come to a halt for a couple weeks while we reassessed the situation to see if it is safe enough to go back into the camps.

This is on top of the infrastructure problems. So, electricity is in extreme shortage in Lebanon. So you may only have a few hours of electricity in a day. In fact there is some creativity around this – they have apps that can know when electricity is on and when its off. The staff that we work with, our colleagues in Lebanon, had to deal with real constraints in terms of just electricity, transportation and getting to places, personal safety issues. Implementing a rigorous scientific study in a context like that, you are constantly challenged. You just don’t have the luxury of relying on, you know, predictable electricity – things are not going to work the way you’d like. Regardless, the work is going forward. To me, it’s almost miraculous. The only reason, I think, the project is moving forward is because of the commitment of the staff and our colleagues in Lebanon, who are very much committed to this work and see it as one of the few positive things they are able to provide for these families.

Boudon: Yes it definitely sounds like a very difficult series of problems you guys have to deal with. But it’s great that you are making progress.

Khoshood: Thank you.

Boudon: Well, I want to thank you for speaking with us today, Kaveh. It’s been wonderful, and the information you provided us was great. Thanks for your time.

Khoshnood: My pleasure.